3. Surgical procedure
Background information
Dr. Jean-Pierre Gardella and Dr. Christian Richelme:
Substantial tissue loss usually necessitates grafting prior to implant placement. However, the
anatomy of the defect determines whether primary implant stabilisation is possible1,5. If this is
possible, it can be performed simultaneously with an autogenous bone graft. This reconstruction
can be optimised by combining the osteoinductive potential of autogenous bone with the
osteoconductive capacity of Geistlich Bio-Oss® as well as its low resorption speed. This technique
can also shorten the treatment time because grafting and implant placement are performed during
the surgical operating phase.
In order to manage this type of situation and improve the biotype of the future implant site,
primary closure of the extraction site is performed with the aid of an epithelial connective tissue
graft.
Surgical technique:
> traumatic extraction technique4.
A
> Closure of the extraction site with an epithelial connective tissue graft which allows:
soft-tissue healing within a short time, while recreating aesthetic crestal morphology, and
re-operation for implant placement before alveolar bone resorption reaches its peak.
> ssessment of the site two months postoperatively (the expanded operation window for
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treatment is obtained by using Geistlich Bio-Oss® or Geistlich Bio-Oss® Collagen).
> btaining of adequate primary stability by adaptation of the drilling sequence.
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> erforming an autogenous bone graft with core bone harvested by trepan (symphyseal region).
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> lacement of Geistlich Bio-Oss® above the graft and onto the outer surface of the vestibular
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cortex. The Geistlich Bio-Gide® membrane is placed over the site in a double layer.
> After 4 months, the second surgical phase is started with a minimal incision.
> Placement of the temporary prosthesis after 6 months of healing.
> Usual prosthesis at 9 months.
Limitations and open questions:
As a result of post-extraction resorption, we sometimes have to perform grafting prior to implant
plac ement3. Despite this compensation, remodelling continues for 18 months following extraction
and occasionally leads to mucosal collapse, which can compromise the aesthetic outcome2. To
make up for this, in eminently aesthetic situations, an excess of soft tissue must be available, which
is why over-correction of the defect at the bony and mucosal level is necessary6.
Fig. 1b See Figure 1a.
Fig. 2a After extraction, in order to solve the problem
of primary closure of the site, an epithelial connective tissue graft was raised from the tuberosity and
grafted to the extraction site.
Fig. 11b See Figure 11a.
Fig. 12a Clinical view of the second phase of surgery.
Fig. 12b See Figure 12a.
Fig. 2b See Figure 2a.
Fig. 3 Clinical view of healing after 10 days.
Fig. 4a Clinical view of healing after 2 months.
Fig. 13 Postoperative radiograph of the 2nd surgical phase. Bone regeneration with very good results
and observed.
Fig. 14a Clinical view of the temporary prosthesis
and after it has been unscrewed.
Fig. 14b See Figure 14a.
Fig. 4b See Figure 4a.
Fig. 5 Clinical view of the defect, the two vestibular
and lingual cortices are swollen. The probe passes
through the drill hole.
Fig. 6 Implant placement.
Fig. 15 Radiograph of the temporary prosthesis in
place.
Fig. 16 Clinical view of the final prosthesis 8 months
after extraction.
Fig. 17 Radiograph of the final prosthesis in place.
Fig. 7 Filling the defect with autogenous bone cores.
Fig. 8 Placement of Geistlich Bio-Oss® to maintain
volume and protect the autogenous graft against
resorption.
Fig. 9 Postoperative radiograph of the first surgical
phase.
Fig. 18a Clinical view of the mucosa after unscrewing of the prosthesis one year post- xtraction (note
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the extent of soft and hard-tissue reconstruction).
Fig. 18b See Figure 18a.
Fig. 10a Geistlich Bio-Gide® arranged in a double
layer.
Concept:
> apid treatment to halt the progression of bone resorption caused by the infectious process.
R
> rimary closure of the extraction site with an epithelial connective tissue graft8.
P
> Combining Geistlich Bio-Oss® with autogenous bone makes it possible:
– combine osteoinduction of the autogenous bone and osteoconduction of
to
Geistlich Bio-Oss®7,9.
– o reduce the volume of autogenous bone harvested, which allows for a less invasive
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surgical technique and more comfortable postoperative course for the patient.
> Use of a Geistlich Bio-Gide® bilayer membrane in double layer technique.
Fig. 1a Tooth 31 is compromised for obvious endodontic reasons. This tooth has already undergone
retrograde surgery and apicectomy.
Fig. 10b See Figure 10a.
Fig. 11a Closure of the site by first intention.
2. Aims of the therapy
> o optimise and speed up soft tissue healing in order to allow peri-implant reconstruction.
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> arly implantation combined with an autogenous bone graft, combining Geistlich Bio-Oss® and
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Geistlich Bio-Gide® 7.
> To restore natural tissue architecture.
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